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A rare case of perfluoro-n-octane in the orbit following vitreoretinal surgery

Published:March 03, 2017DOI:https://doi.org/10.1016/j.jcjo.2017.01.002
      Perfluorocarbon liquids (PFCLs) are versatile vitreous substitutes that have been revolutionary in the advancement of vitreoretinal surgery.
      • Chang S.
      • Ozmert E.
      • Zimmerman N.J.
      Intraoperative perfluorocarbon liquids in the management of proliferative vitreoretinopathy.
      • Chang S.
      • Lincoff H.
      • Zimmerman N.J.
      • Fuchs W.
      Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids.
      • Chang S.
      • Reppucci V.
      • Zimmerman N.J.
      • Heinemann M.H.
      • Coleman D.J.
      Perfluorocarbon liquids in the management of traumatic retinal detachments.
      Characteristics of PFCLs include transparency, clarity, low viscosity, and high density.
      • Peyman G.A.
      • Schulman J.A.
      • Sullivan B.
      Perfluorocarbon liquids in ophthalmology.
      These properties make PFCLs ideal substances to unfold and stabilize the retina, in addition to displacing subretinal fluid anteriorly.
      • Sparrow J.R.
      • Jayakumar A.
      • Berrocal M.
      • Ozmert E.
      • Chang S.
      Experimental studies of the combined use of vitreous substitutes of high and low specific gravity.
      PFCLs are used intraoperatively but are removed at the end of surgery to avoid inflammation mediated by toxicity that has been reported in animal and human studies.
      • Velikay M.
      • Wedrich A.
      • Stolba U.
      • Datlinger P.
      • Li Y.
      • Binder S.
      Experimental long-term vitreous replacement with purified and nonpurified perfluorodecalin.
      • Figueroa M.S.
      • Casas D.R.
      Inflammation induced by perfluorocarbon liquid: intra- and postoperative use.
      We report a case of retained perfluoro-n-octane (PFO), a PFCL, and subsequent leakage into the orbit after its use for a retinal detachment in a globe with a perforating eye injury.
      A 36-year-old male presented after penetrating trauma to his right eye after using a chisel. On clinical examination, visual acuities were hand motions OD and 20/30 OS. An entry site was present on the superior lid as well as through the conjunctiva approximately 6 mm posterior to the limbus. The lens was clear. A computed tomography (CT) scan of the orbits demonstrated a metallic intraocular foreign body (IOFB) temporal to the macula (Fig. 1A). The patient underwent surgical repair on the same day.
      Fig. 1
      Fig. 1(A) Computed tomography of the orbits demonstrating the intraocular foreign body. (B) Computed tomography of the orbits showing multiple globular-like hyperdensities representing the injected perfluoro-n-octane, which is now retained within the orbit.
      The scleral entry site was identified superonasally, stretching 3 to 5 mm from the limbus, and was closed with 8-0 nylon sutures. A 23-gauge 3-port vitrectomy was commenced. The hyaloid was disinserted from the disc and a complete vitrectomy was performed. A large exit wound was visible nasal to the disc and was plugged with blood and vitreous. Part of the IOFB was visible through the nasal wound and a decision was made to attempt to remove it. The vitreous and blood that was plugging the exit wound was removed. The fluid in the vitreous cavity, however, began to infuse into the orbital cavity through the rupture site. At this point, the globe began to collapse because of posterior pressure. The IOFB could not be visualized, and a large bullous, superonasal retinal detachment developed. PFO was injected into the vitreous cavity to flatten the retina. Laser was applied surrounding the IOFB exit wound. During air–fluid exchange it was evident that the volume of PFO present was less than what was injected to flatten the retina. The remaining PFO was removed, and silicone oil was injected into the vitreous cavity. All ports were sutured.
      Postoperatively, his vision was counting fingers and intraocular pressures were within normal limits. The retina initially remained flat under the silicone oil. He developed scleritis 2 weeks after the procedure, which was treated successfully with a course of oral prednisone 1 mg/kg for 3 weeks, with subsequent tapering of the dose over a further 2 weeks. We believe that the scleritis was secondary to retained PFO in the orbit. A CT scan of the orbits demonstrated multiple globular-like hyperdensities representing the injected PFO in the orbit both intraconally and extraconally (Fig. 1B). The position of the IOFB remained unchanged.
      Four weeks postoperatively, his vision remained counting fingers, and he developed a redetachment because of proliferative vitreoretinopathy. A repeat vitrectomy with membrane peeling was performed, and silicone oil was reinserted. The retina remained attached under silicone oil; however, his vision dropped to hand motions (Fig. 2). Exophthalmometry revealed a 2-mm proptosis in the right eye. Extraocular motility examination was normal. He had no neurologic fallout and no evidence of orbital inflammation or discomfort.
      Fig. 2
      Fig. 2Wide-angle fundus photograph 5 months postoperatively. The retina remains flat under silicone oil.

      Discussion

      The literature directly studying the effect of PFCLs in the orbit is scarce. A Brazilian team published the only other report of such an event in 2011 in which a patient presented with ocular trauma after a hammering accident.
      • Lavezzo M.M.
      • Hokazono K.
      • Zacharias L.C.
      • Takahashi W.Y.
      Perfluoro-n-octane in orbital cavity after posterior vitrectomy and suture of eye perforating injury: case report.
      A vitrectomy was performed using PFO, and 4 days postoperatively the patient presented with eyelid edema and proptosis. A CT scan of the orbits demonstrated numerous hyperdense opacities whose appearance was suggestive of PFO. Over the course of 1 year, the patient reported no pain or other complaints, and the proptosis remained stable.
      In this case, we surmise that the postoperative scleritis could be associated with the posterior PFO leak, as inflammatory properties of the PFO have been previously described.
      • Velikay M.
      • Wedrich A.
      • Stolba U.
      • Datlinger P.
      • Li Y.
      • Binder S.
      Experimental long-term vitreous replacement with purified and nonpurified perfluorodecalin.
      • Figueroa M.S.
      • Casas D.R.
      Inflammation induced by perfluorocarbon liquid: intra- and postoperative use.
      Considering the retinal redetachment on follow-up, we decided not to proceed with any intraorbital foreign body or leaked PFO removal because manipulation of the globe during orbital surgery could pose a risk for redetachment or reopening the posterior exit wound, and after resolution of the scleritis there were no orbital inflammatory signs to warrant surgical treatment for that purpose. Furthermore, complete removal of PFO would prove challenging if not impossible because of its liquid nature that would pose difficulties in identifying it within the orbit as well as the multiple locations secondary to local spread. It is possible that a localized inflammatory reaction within the orbit could cause fibrosis and encapsulation of the PFO.

      Conclusions

      PFCLs should be avoided in perforating eye injuries because they have a low surface tension and can easily track into the orbit. Once in the orbit, removal could prove challenging and unsuccessful. Posterior extension of PFCLs into the central nervous system has not been identified and is unlikely due to anatomical boundaries such as orbital fat, tenons capsule, and optic nerve sheath.

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